
To illustrate this, from our perspective, there are two
basic viewpoints on what the answer is to the question where does the failure come from? For the sake of simplicity, we
will just call them the Broken Parts
and the Functioning System
perspectives. Each perspective has its own assumptions as to what causes
accidents, what causes safety, where the problems in organizations are and what
the safety professional should do about it. We will discuss each perspective in
kind.
The Failure Comes
from Broken Parts
The first perspective, the perspective held by many in the
safety profession, is that when an organization experiences failure, such as an
accident, the failure came because something broke or failed. Everything was
working fine, but then something or someone screwed up and that caused the
failure. So, for example, an employee is injured when she put her arm into a
piece of equipment and is partially pulled in. The failure from the perspective
of the Broken Parts camp comes from
erratic employees. The employee should not have put her arm in the machine to
begin with. The broken part in this case is the employee, usually in their
decision-making processes. If it weren’t for this then the accident would not
have happened.
What causes accidents
and what causes safety?
From the Broken Parts perspective,
accidents are caused when something in the organization deviates from the
intended design. This could be from equipment that fails, but most likely is
from a person deviating from the rules or procedures put in place.
Conversely then, safety is created
when everything and everyone follows the plan. It is only when we deviate that
accidents happen. The organization itself is basically safe. It is only through
deviation that unsafety creeps in.
Where do we look?
Following from the above, when an
accident happens, all we have to do is look for those parts of our organization
that deviated from the intended design. This is the so-called “root cause” or
“root causes”.
If we want to prevent accidents,
all we need to do is prevent deviations and variability in performance. We want
things to be standard and uniform. Only when things begin to vary in their
performance do we have problems.
What do we fix?
Again, it follows the above that
our job is to find those parts that are broken or in the process of breaking
and either fix them or replace them. Again, typically the issue is one of human
behavior, because people are typically less reliable than machines. So we need
to fix the individual’s behavior through typical behavior interventions, up to
and including termination. Often we don’t go that far though, so we just
implement more controls in the form of rules, policies, procedures,
observations, audits, etc. If we decide to get more “enlightened” then we look
for opportunities to engineer the human out of the system entirely through
automation.
The Failure Comes
from the Functioning System
From the second perspective, one not held by many in the
safety profession so far, is that failure results from how the system normally
functions. Organizations are always working in a fluid, imperfect, resource
constrained world, which forces them to balance competing goals. This process
of balancing is remarkably successful…until it’s not. Essentially failure and
success have the same causes. Using the example from above, the employee put
her arm in the machine not because of a disregard for safety rules, but because
there was no other way to do the task available to her. The organization simply
couldn’t shut the machine down to do the task the employee was doing without
cutting their production almost in half. Further, this task was routinely done,
multiple times a day, around the clock, every day without incident. So the day
her arm was pulled into the machine was a day like any other…except today the
things that normally happened came together in abnormal ways to create the
accident.
What causes accidents
and what causes safety?
In the Functioning System
perspective, accidents are an unintended consequence of normal performance
variability. Put another way, accidents are an outcome that was designed into
your system (as David Woods says, systems work as designed, but not as
intended). People have to make trade-offs in order to function in an imperfect,
complex and resource constrained world. In such an environment, deviations and
variability in performance are normal and often required in order to get the
job done. This does not make them right, but on days where you have accidents
and days where you have none, you will have both deviations and variability.
Safety is created in organizations
not when we force them to meet an unrealistic standard, but when we help
facilitate successful performance. By assisting people in making better
trade-offs, smarter adaptations and designing systems that work with people
rather than constrain them we create expertise and safety.
Where do we look?
Following from the above, when an
accident happens it provides us an opportunity to see how our system produced
an outcome that we didn’t expect or intend and change that system. Essentially
we are looking for how the system normally functions and why that functioning
led to this negative outcome. This will tell us where the opportunities for
improvement are.
Before accidents happen, because
success and failure have the same cause, it makes no sense to wait for an
accident to happen. For the Functioning System perspective, similar things
happen on both the days you do and do not have accidents. So you can learn just
as much on days you have no accidents as you can on days you do not have
accidents. Looking for those parts in your system where work becomes difficult,
where people have to overcome things in order to get work done will help you
find where risk is creeping into your system and where you can make work easier
to get done.
What do we fix?
Finally, in the Functioning System
perspective, doing things like focusing on any individual to improve things in
the future makes no sense. People don’t fail like machines do, so blame seems a
bit nonsensical in this light. But we obviously want less accidents and better
performance in the future. So we look for ways to make it easier for people to
accomplish goals, make sure that the proper resources are readily available
(from the perspective of the worker, not your perspective) and to find ways to
streamline workflows in a way that makes success possible in varying conditions
(i.e., resilient). We are more interested in facilitating performance rather
than constraining it and harnessing the ability of people to adapt to their
circumstances to achieve success. What this looks like will obviously vary
depending upon the context of the work.
What’s Your
Perspective?
In safety we often do not reflect on our worldview or mental
models and how those can guide us down a path to where certain problems and
solutions seem obvious and others seem crazy. We think it’s probably a good
idea to take a step back every now and again to identify what your perspective
is and ask whether it’s leading you in the direction you’re happy with. Many
times, these worldviews are constructed in such a way that it’s very hard to
identify the flaws in them from the inside. It’s only when we step outside
ourselves, often with the help of others, that we see them. But we think it’s
well worth it.
Clearly from the above, we think that when it comes to the
question of where failures come from the Functioning System perspective is
better, although it currently is not the most popular one. What do you think?
Where does the failure come from?